[Editor's Note: PEDs in MMA is a two-part series. Next week, an installment on the drug-testing landscape in MMA, and how regulators, athletes and promoters are adapting.]

I'll post the second part in this thread, as well.

Quote:

Mar 23, 2012 - In the days after Quinton "Rampage" Jackson became the latest fighter to acknowledge using testosterone replacement therapy (TRT), Nevada state athletic commission executive director Keith Kizer's phone began to light up. On the other end were fighters and managers interested in finding out how to obtain a TRT exemption.

Kizer, who had heard about Jackson's interview with Fighters Only acknowledging his usage, was not surprised. In his comments, Jackson claimed that "a lot of fighters are probably doing it but not telling anyone." That quote has since been removed from the interview, but its echo has created a stir in the mixed martial arts world, suggesting that legitimizing TRT treatment was easy.

Jackson is not only the latest of the divulged names using TRT, but also its loudest proponent. But contrary to popular belief, the number of fighters legally using TRT with the permission of state athletic commissions is quite low.

How low?

In its entire history, the Nevada state athletic commission has granted only three therapeutic use exemptions (TUE's) for TRT, Kizer told MMA Fighting. The only individuals to receive exemptions have been Dan Henderson, Todd Duffee, and most recently, Shane Roller in 2011. New Jersey Athletic Control board legal counsel Nick Lembo could not offer a specific number but said that state had given "less than five" TUE's for TRT in its history. In Ohio, only Henderson and Strikeforce fighter Bristol Marunde have ever been approved for TRT use, its state athletic commission executive director Bernie Profato told MMA Fighting.

Contrast that with the reaction of say, Dr. Don Catlin, who sits on the International Olympic Committee's medical commission responsible for reviewing TUE applications for Olympic athletes. In a recent interview with MMA Fighting regarding the possibility of active fighters needing TUE’s for TRT in MMA, Catlin remarked that the whole thing was "a joke."

Those types of broad criticisms are troubling to some combat sports regulators who feel that their goals of toeing the line between sport safety and being responsive to individual health situations are being undermined.

"I hear things like, 'Oh everyone can do it,'" Kizer said. "Well, how many exemptions have [the IOC] given out? Two. Well, we've given out three in 12 years."

According to Catlin along with many other critics, the possibility of professional athletes in their 30s needing TRT is so low, it's almost completely zero.

That research, along with how traumatic brain injuries impact the pituitary gland, is being continued by Dr. Daniel F. Kelly, the director of the Brain Center and Pituitary Disorders Program at the John Wayne Cancer Institute at Saint John's Health Center in Santa Monica, California.

Kelly is currently in the midst of a study of 75 former NFL players that is expected to be published around the end of 2012. In an interview with MMA Fighting, Kelly said that preliminary data from the study suggests that pituitary damage is occurring in a subset of the retirees.

Extrapolated to MMA, it's not much of a leap to suggest that similar injuries can be occurring to this sport's fighters, for whom getting hit in the head is a daily occurrence. In fact, Dr. Fahrettin Kelestimur, a professor of endocrinology at Erciyes University in Turkey who authored the 2006 study, told MMA Fighting that the most common damage has caused growth hormone deficiency and hypogonadism, respectively. The latter problem was the one cited by Chael Sonnen as the necessity of his TRT treatments during his appeal of a California state athletic commission suspension.

"These fighters are getting repeated insults to the head, sometimes more than concussive events," Kelly said. "And if you did a careful analysis of those people, I'm sure you'd see a significant rate of pituitary gland dysfunction. That's my prediction."

The issue is complicated by the fact that it is not always possible to determine the cause of pituitary damage, according to Kelly. It's well known that steroid abuse can also damage the pituitary gland, but head trauma can cause the same affect.

That makes things cloudier for regulators like Kizer and Lembo, who work for two of the sport's leading commissions.

At the same time, they along with other regulators believe it’s important not to punish the athletes that come forward with a legitimate need by banning TRT outright. While the long-held belief that steroid use as the main cause of low testosterone among athletes might be true, it’s by no means a catch-all.

That knowledge simply just isn’t widespread. Most of the people interviewed for this story were unaware that pituitary damage could be caused by repeated blows to the head, as Kelly, the brain and pituitary expert agreed.

"Is that incrementally damaging the connection between the brain and pituitary? I think it probably is," he said. "But can we prove that there’s an exposure component that’s incrementally adding up even if it’s not even considered a concussion. I think that’s probably the case."

While MMA often points to its safety record, there are variables to the sport that cannot be controlled. Chief among them is what goes on in the gyms during training camp. While fighters who suffer knockout losses in competition are medically suspended in order to give them time to recover, those periods are rarely enforced. Some of them can’t be due to simple logistics.

If a fighter competes in Texas, for example, but calls Brazil home, there is no real way to check up on him and ensure he’s letting his brain recover from the trauma it received. Most good coaches will try to keep their athletes on the sidelines and away from head strikes in this critical recovery phase, but it’s not like that everywhere.

Take, for instance, Pat Barry’s recent explanation of why he hoped to visit Croatia soon to get in some training.

"Out there, you can punch and kick guys completely unconscious and they show up the next day," he said. " Whereas here, you can punch and kick some guys, and sometimes they don’t come back for the rest of the week."

"Which is probably a good idea," UFC president Dana White interjected.

Barry's seeming insensitivity to head injuries might be ingrained in his mentality as a fighter who is trained to be fearless even in the heat of battle, but it also might be from an attitude that is generationally rooted, though changing. A recent Centers for Disease Control and Prevention report noted that emergency room visits for children and adolescents due to sports and recreation-related traumatic brain injuries were up 60 percent in the last decade. The organization’s director of the National Center for Injury Prevention and Control attributed to the rise not to increased incidences, but to growing awareness of the dangers caused by brain injuries.

Attention to the problem of brain injury has also been slow to come to pro sports. In 2008, the collaborative Center for the Study of Traumatic Encephalopathy was founded to study brain injury, and their work has changed the NFL’s outlook on concussions and head trauma, causing rule changes in 2009 that focused on player safety. This even though as a league, the NFL has had a multi-decade head start on MMA when it comes to head injuries. MMA commissions in some instances have only been sanctioning the sport for a year or two and are still drafting regulations.
As it stands now, most commissions have no tests in place that would determine this type of problem.

Only a handful of state commissions require an MRI in order to grant a fighter’s license, but MRI’s don’t always show the problem, anyway. A blood draw is more likely to determine if an issue exists, according to Kelly. Tests for luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, growth hormone (GH) and IGF-1 (insulin-like growth factor 1) could serve as an effective screening tool to determine any pituitary damage.

Most of the blood work done through commissions prior to licensing though, is solely to test for contagious diseases.

A big problem when it comes to changing medical technology is cost. Ohio Athletic Commission executive director Bernie Profato likened it to medical issues in the world at large, recounting the story of how the son of a close friend died from a rare blood disease that doctors didn’t have the means to handle because of a lack of money to fund research.

"The more this stuff comes up, the more time medical people put into it, it extends our knowledge of it," he said. "We’re regulators, not medical people. We do what we can to put these athletes in the safest environment."

Only a handful of the regulators MMA Fighting spoke with had heard of the studies linking brain trauma with pituitary damage, but most acknowledged that such conditions are exactly why TRT TUE’s shouldn’t always be passed off as an attempt to fleece the system.

"It’s very rare, but there are some legitimate needs," Lembo said. "My biggest concern is that most commissions don’t even test for these things in the first place so we’re over-penalizing the people that are coming forward and saying, ‘Hey, do whatever you want to me. Test me before and after the fight. Test me randomly. I need this, I’m on it and I’m going to be within normal limits.’ There are a lot of commissions who don’t believe in TUE’s for any reason, but why be hard on the ones coming forward?"

Dr. Kelly, who has been working on issues pertaining to the pituitary gland for nearly 20 years, in 2008 co-authored a study that concluded chronic hypopituitarism occurred in approximately 20 percent of patients who had suffered mild, moderate or traumatic brain injury.

With the repetitive head impacts from training and competing from month to month and year to year, it’s no wonder then that professional fighters could be subject to these same types of injuries. While finishing up his NFL research, Kelly is also interested in studying boxers and, possibly, mixed martial artists to gain a more definitive understanding of a problem that still remains mostly hidden away.

"I’m sure there’s a certain level of it going on," he said. "I guess what’s really amazing, if you look at it another way, is how infrequently it occurs, and how sturdy the system is, how much damage it can take. The pituitary gland is this tiny little thing that’s less than a centimeter cubed. It’s sitting in a little, bony depression in the skull base and it’s getting banged around, and the connection is getting banged around repeatedly, yet it keeps it on ticking in most people. It’s a pretty resilient system, but only up to a point."

"I hear things like, 'Oh everyone can do it,'" Kizer said. "Well, how many exemptions have [the IOC] given out? Two. Well, we've given out three in 12 years."

According to Catlin along with many other critics, the possibility of professional athletes in their 30s needing TRT is so low, it's almost completely zero.

But new research might show those long-held beliefs to be incorrect.

The science of brain injury is still relatively new, and developing rapidly. In 2007, a paper published in the Journal of Athletic Training reported the first known connection between mild concussions and hypopituitarism, a deficiency that can lead to low testosterone.

That research, along with how traumatic brain injuries impact the pituitary gland, is being continued by Dr. Daniel F. Kelly, the director of the Brain Center and Pituitary Disorders Program at the John Wayne Cancer Institute at Saint John's Health Center in Santa Monica, California.

Kelly is currently in the midst of a study of 75 former NFL players that is expected to be published around the end of 2012. In an interview with MMA Fighting, Kelly said that preliminary data from the study suggests that pituitary damage is occurring in a subset of the retirees.

That study seems to corroborate a 2006 finding in Turkey that found that head injuries incurred by pro kickboxers have resulted in damage to the pituitary gland.

This isn't new information to the general public. The "scientific connection" between hits to the head and other health problems later in life is basically the train of thought amongst anybody who has ever had their bell rung and those too afraid to actually find out what it feels like.

Their conclusion is that getting hit in the head can damage to the pituitary gland? I didn't go to medical school, but I would think that getting hit in the head can potentially damage anything inside your head.

Mar 30, 2012 - When it comes to drugs in combat sports, Nick Lembo has basically seen it all. Like the time a fighter tested positive for PCP after a bout. Yes, angel dust, the hallucinatory drug that distorts reality, prompts violence and numbs the brain's pain receptors.

"That guy didn't feel anything during that fight," said Lembo, longtime legal counsel to the New Jersey Athletic Control Board.

Across the country in Nevada, Nick Diaz and his team are preparing to mount a defense that centers on the theory that his recent positive test for marijuana metabolites proved that his usage came out of competition, a result that would not see him serve any suspension even under the strict bylaws of the World Anti-Doping Agency (WADA) that monitors international sport.

Those two cases represent the two extremes of drug testing in sports. One is a black-and-white issue with a clear offense, the other is a matter of interpretation.

In MMA, drugs and drug testing have been at the forefront of debate recently, due to situations like Diazís positive test, Quinton "Rampage" Jacksonís testosterone replacement therapy (TRT) admission, and Muhammed "King Mo" Lawalís nine-month steroids suspension, the result, he says of an over-the-counter supplement with a banned ingredient.

Those high-profile situations have intensified conversations about the way the sport is monitored. UFC president Dana White likes to say that because of government oversight, his athletes are the most regulated in the world, but a closer look shows thatís not the case everywhere.

The promotionís most recent, show, for example, took place in Sydney, Australia, and was overseen by the Combat Sports Authority of New South Wales. Their spokesperson Michelle Neathercote, however, told MMA Fighting that "The Combat Sports Authority does not conduct drug testing. Any drug testing arrangements are a matter for the UFC." In those instances, the UFC acts as its own regulatory body, with its vice president of regulatory affairs Marc Ratner handling issues related to drug testing.

Thatís not that unusual when the UFC goes international, and global business is a major piece of their expansion, with six out of their last 20 events taking place outside of U.S. borders and at least five others scheduled for 2012.

The UFC faced the same scenario in Tokyo just one week before it was in Australia. Some of their fastest-growing markets have yet to embrace drug testing. In Rio, where they will host their third event in a 10-month span this June, there is no commission enforcing drug testing. Even in Toronto, which hosted the largest event in North American MMA history, drug testing isnít required. Office of the Athletics Commissioner senior advisor Richard Hustwick told MMA Fighting that testing is only done if it is written into bout contracts. The Athletics Commissioner will oversee the administering of the test, while the promoter pays for its cost.

Even stateside, there are problems. The state of Washington only has mandatory testing for title bouts. Other states, like Louisiana, have no formally written testing policy at all.

That often leaves the UFC in a position where it must help police itself, and leads to skepticism from the public who distrust their willingness to disclose results. On one hand, they have twice suspended star middleweight Chris Leben stemming from self-regulated events. On the other, they never divulged the positive drug test of Tyson Griffin at UFC 123 before it was discovered by MMA blog BloodyElbow.com over one year later. After news of the story broke, the UFC issued a statement saying that while they followed the Michigan Unarmed Combat Commissionís 100-day suspension, they noted that it was the state that "did not make this information public."

The fact is, there are still situations in which the UFC works hand-in-hand with state regulators to enforce drug testing, mostly by footing the bill.

Alvin Topham, who chairs the Louisiana Boxing and Wrestling Commission, detailed that process during an interview with MMA Fighting.

When the UFC comes to the state, as they did last September, they insist upon drug testing. The commission will administer the tests, select a laboratory to process them, and pay the initial bill. They will also be the first to receive the results, which they will eventually pass along to the UFC.

The promotion later reimburses them for the cost.

The reason for this setup? The expense. Topham told MMA Fighting that the commission doesnít receive a single cent of funding from the state government. Instead, it is self-funded through event gate taxes and licensing. The costs of random testing all events would quickly whittle away their cash reserves, so instead, they concentrate on major shows, using the deeper pockets of bigger promotions like UFC and Bellator to pay for the screenings.

"Theyíre footing the bill, but the way weíre doing it is safeguarding against impropriety," said Topham, who has served on the commission since 1992. "If anyone questions my integrity, thatís fine. They can say what they want to say. But I have no investment in the UFC. I donít work for them. This is an arrangement, and weíre ultimately administering the testing."

Many critics contend that fight week testing isnít enough, anyway, that fighters should be tested out-of-competition. Just this week, the Nevada commission took advantage of a pre-fight press conference to test six UFC fighters scheduled to compete on a May 26 event, the first time that had been done. Regulators simply donít have the budgets to test fighters when theyíre one time zone away, let alone across the world, as often happens in MMA.

It's been suggested that the burden should be shouldered by the UFC.

According to White, while the promotion recently started drug testing newly contracted athletes, more extensive random, out-of-competition testing would also stretch the promotionís resources thin.

"We have 375 guys under contract," he said. "Weíre doing a zillion fights a year. Weíre traveling all over the world and doing all these other things weíre doing. Now, do you really think that we can crack down and just f------ chase these guys around, everywhere they live, all over the world, and just randomly test these guys all the time? On top of all the other things weíre doing? You have to really sit back and think, to use a little reality and common sense."

Commissions Playing Catch-up on TUE's

While simple drug screenings are hard enough, the new battleground in drugs in sports is testosterone. Depending on who you ask, testosterone can be the best, worst and most confounding drug in the sports world, sometimes all at once, a viewpoint recently summed up by White.

"I think that this whole testosterone therapy (TRT) thing works for guys who absolutely need it, but I think it's a messy loophole," he said.

For those who legitimately need it, TRT can be a life-changer, addressing issues related to decreased muscle mass, over-fatigue, depression, osteoporosis, and as we all know from the commercials, sex drive. But the key is whether the use is legitimate. TRT, usually administered either through an injection, a patch or gel, successfully addresses these issues, but if abused, could offer an advantage to a professional athlete.

Thatís particularly worrisome in MMA, where the consequences of PEDís extend far past what they may do to the offending party. It can be a problem for the unwitting opponent, as well as the pressure it places on everyone else to keep up.

"I think a lot of fighters, and itís not an excuse but it is a reason, in the past used steroids not to get an advantage but because they thought they needed it to have a level playing field," Nevada state athletic commission executive director Keith Kizer told MMA Fighting. "My opponentís doing it so I have to. I think weíre moving away from that. Most guys arenít doing it and those who are doing it are hopefully getting caught by the commissions. But now Iím worried TRT is going to be that way. If my opponentís doing it, I donít want him to have an unfair advantage."

Publicly ask a professional fighter his opinion on TRT, and most likely you'll get one of two responses. Either they have no opinion because they don't consider themselves knowledgeable enough to comment on the subject, or they, like many in the population at large, consider it to be cheating.

"Itís a touchy subject," UFC middleweight Alan Belcher told MMA Fighting. "I know it's supposed to be a case-by-case basis, but probably like 99 percent of the time, theyíre cheating. Theyíre lying and the doctor is helping them out."

The controversy even cuts right through friendships. Former M-1 light-heavyweight champ Vinny Magalhaes has worked with exempted TRT user Dan Henderson many times, but believes the therapy shouldn't be allowed in MMA.

"Iíve been in Danís camp for three years," he said. "Dan trains, heíd go months with 4-5 injuries. I kind of get why he feels like he has to do it. But for me, if youíre 40 years old, youíre not supposed to have the energy of a 25-year-old guy. If you feel like you canít perform, maybe itís just time for you to quit better than to cheat. Otherwise itís going to become like, hell, Iím 27 but I want to have the strength of two horses so Iím going to take a bunch of steroids. Itís wrong, in my opinion."

Under proper doctorís supervision, TRT isn't going to create a superman, but simply restore the bodyís natural testosterone levels. The question then becomes, what is the proper supervision?

States that allow exemptions offer guidelines that must be followed before the exemption is ever granted. Nevada and New Jersey shared their rules with MMA Fighting, including the documentation that must be followed by any applicant.

In Nevada, a fighter must submit an application for a TUE at least 20 days before a fight. Along with it, he must provide results of no fewer than five tests, measuring things like total serum testosterone level (on separate occasions), luteinizing hormone, follicle stimulating hormone and measurement of hemoglobin and hematrocrit levels. The commission also reserves the right to require additional tests measuring serum prolactin and iron saturation, pituitary function testing, and MRI of the sella turcica. They must also be able to prove there is no reasonable alternative therapy.

According to Kizer, that stops many inquiries in their tracks.

In New Jersey, fighters must provide similar records, again demonstrating that levels have been consistently below even the low end of "low normal."

But other states have no such procedures in place for TUEís or any other medically necessary drug. Some states, like Tennessee, handle situations on a case-by-case basis. Spokespeople for the Ohio and Illinois athletic commissions both confirmed that they currently have no procedure in place, though both said they are in the process of being drafted. Asked if Chael Sonnen, a TRT user, notified the state of his use prior to his UFC on FOX 2 matchup with Michael Bisping, Illinois Department of Financial & Professional Regulation spokesperson Susan Hofer told MMA Fighting, "Since we have no therapeutic use rules in place, there would have been nothing to compel an athlete to tell us if they were using any particular therapy in advance."

The same question was asked to a Department of Licensing and Regulation official in Texas, where Sonnen fought Brian Stann last October. She would not comment without first seeking the attorney generalís opinion, which was unavailable by press time. Instead, she referred MMA Fighting to their existing rules, which only requires an athlete to inform its executive director of prescription usages "at least 24 hours prior to the bout," too little time to determine need, according to most experts.

In an effort to address the issue, the Association of Boxing Commissions plans to address TUEís at its upcoming July convention, which is attended by many of the countryís state athletic board heads.

"Iíve got questions myself," said Ohioís Profato. "Weíll speak to their medical people on this and see where weíre going. I donít know that we should bar people with TUEís if they need it medically. Our goal is to make sure when two people get in the cage, neither fighter is at an advantage or disadvantage."

Even with procedures in place, some critics contend itís not enough. When it comes to the growing use of testosterone, most states use a 6:1 testosterone to epitestosterone ratio (T/E) as their cutoff for flagging a positive result (WADA has used a more conservative 4:1 ratio since 2007). Others cite the testing as insufficient.

Most experts cite the carbon isotope ratio test (CIR) as the most effective means of catching cheats. Instead of looking at T/E ratio, it determines whether the substance in the body is natural or synthetic.

From the regulatorsí points of view though, the expense related to the test makes it cost-prohibitive given their budgets. Though no one would go on record with the cost of the test, Dr. Anthony Butch, who is the director of the UCLA Olympic Analytical Laboratory -- the lab used by California to flag Chael Sonnenís test in 2010 -- told MMA Fighting that a CIR is "typically at least five times more expensive" than a simple screening for testosterone metabolites, but far more effective.

"Given that some athletes do not see a significant elevation in the T/E ratio after taking testosterone, or a precursor of testosterone which would then trigger CIR testing, the CIR testing can be a more sensitive first-line test," he said.

If all of that has you beginning to drown in information right now, thatís exactly how it sometimes feels for regulators like Kizer and Lembo, who work for two of the sport's leading commissions. Because TUEís can be applied not only to TRT, but drugs related to other conditions including attention deficit hyperactivity disorder, asthma and more. At least one commission, New Jersey, has in the past received a TUE request for medical marijuana, though Lembo would not say whether it was granted.

Right now, most of the leading state commissions have declined to disqualify athletes from competition for a medical condition out of hand, but itís a hot-button issue regardless of the cause.

"If someone did abuse performance-enhancing drugs at 18 or 20, and theyíre 32 now, I donít know if you disqualify them because they did that," Lembo said.

For now, it's not ultimately his decision, anyway. New Jersey uses a review board consisting of three expert physicians who are blinded as to the athlete's identity as well as the other physicians in the decision-making process, its lead ringside physician Dr. Sherry Wulkan told MMA Fighting.

Over the years, New Jersey, like Nevada, has denied more TRT TUE's than it has granted.

The spotlight on this issue has focused squarely on MMA -- and more specifically, the UFC (Bellator's CEO Bjorn Rebney told MMA Fighting that he was unaware of anyone on his roster undergoing the therapy). But it's not solely an issue here. Other contact sports have also seen the phenomenon. NFL senior vice president of public relations Greg Aiello told MMA Fighting that "about half a dozen" TRT TUE's have been granted in the history of the program, going back to 1990. The NHL also confirmed that they grant exemptions for TRT, though they would not release specific numbers on their program.

Thatís not to say that there arenít athletes trying to beat the system. Even Kizer admits that its doubtful unapproved testosterone users will be caught if they stay within normal levels.

"Itís no different than non-approved use of steroids," he said. "If you cycle properly, youíll probably be able to cheat the test, unfortunately. But thatís why we try to do in-training testing. People think itís easy to beat a test. Itís not impossible by any means, but itís not easy. All we can do is try to have better testing and more testing."

Now, hereís the kicker to all of this. Say you spend every last dollar your commission has to test every fighter on every card. You randomly test out-of-competition, you spring for the more effective but more expensive CIR testing. You do all that, and everything seems fine. Guess what? You might still have cheaters in your midst. In February, a WADA report suggested that their research indicated that they are only catching one in every five drug cheats, and they are considered the gold standard for testing.

Itís only going to get more difficult. According to multiple experts, the next frontier is gene doping, a process which injects DNA into existing genes to enhance athletic performance.

For now, itís not known if thereís any usable test in existence that would catch a gene doper. Why? Because thereís no way to tell an athleteís genetic code without already having it on file. And thereís no way to have it on file without having a biopsy. How many athletes are going to voluntarily submit to that in the name of fair play?

History has proven that wherever an opportunity to take an edge exists, someone will take it. Despite the best effort of regulators to test, of promoters to condemn, and of fans to rebuke drug cheats, the system seems destined to be imperfect, a cause ultimately both righteous and hopeless.

been saying this for a while .. the guys on TRT are cheating and getting a major advantage ... sure they may not be breaking any rules, but imo they are not playing within the "spirit" of the rules ...